Like smokers, most e-cigarette users want to quit vaping.[1] But how? A Canadian Journal of Cardiology article released early online is entitled “Vaping Cessation Interventions in Former Smokers: A Review.”[2]

Noting serious e-cigarette health risks, a literature review by Katherine Huerne, MSc and Mark J. Eisenberg, MD MPH revealed that vaping cessation research is almost non-existent.

They suggest a pressing need for official guidelines similar to those for smoking cessation, asserting that, until then, physicians and clinicians must anecdotally adapt smoking cessation interventions for use in vaping cessation, specifically recommending nicotine replacement therapy (NRT), varenicline, and bupropion.[2]

Not mentioned by Huerne and Eisenberg is how most former e-cigarette users are breaking nicotine's grip upon their minds and lives, via “cold turkey (abrupt nicotine cessation).”

Cessation Guidelines Ignore “Most” Quitting

A decade prior to the FDA’s 1984 approval of nicotine gum, “cold turkey” was defined as “abrupt complete cessation of the use of an addictive drug either voluntarily or under medical supervision.”[3]

Despite acknowledging that “most smokers attempting to quit today still make unaided quit attempts” and that “many” succeed, the most recent U.S. tobacco cessation guideline limited the evidence used in formulating quitting method recommendations to efficacy findings from randomized, placebo/comparison controlled trials (RCTs).[4]

Disregarding population-level productivity and effectiveness, the U.S. guideline does not mention that “most” who succeed do so cold turkey (free PDF of Professor Chapman's 2022 book "Quit smoking weapons of mass distraction"), including family practice patients,[5] bladder cancer patients,[6] head and neck cancer patients,[7][8] and pregnancy patients.[9]

Whether analyzing light or heavy smokers[10] or after adjusting for a dozen known confounders,[11] unassisted real-world effectiveness rates are generally superior to over-the-counter NRT [5,7-9,11][12][13][14][15][16], but not always,[17] and often found more effective than prescription quitting products.[5,7-8,11,14]

As with smoking cessation, should vaping cessation recommendations turn a blind eye to quitting’s historic productivity workhorse? Will abrupt nicotine cessation real-world effectiveness continue to be ignored in favor of replacement nicotine and alternative dopamine pathway agonist or partial agonist clinical efficacy?[4]

Absent from all smoking cessation randomized clinical trials (RCT) was spontaneous or unplanned cessation,[18][19] the smoker who awoke, decided that today is the day, and mustered the courage to begin saying “no” to use urges.

Instead, guidelines mirror researcher-delayed and controlled cessation within non-existent real-world quitting environments. For example, what percentage of varenicline users receive the 25 counseling/support sessions seen in FDA varenicline approval studies?[20] Also, if the timing and substance of counseling are tailored to support the successful transfer to and use of the product being evaluated, what value is it to the placebo arm?

In trying to harmonize the massive disparity between RCT efficacy and observational effectiveness, I hypothesize that placebo-controlled findings significantly reflect the satisfaction and frustration of expectations within a population of mostly product-seeking smokers.

Nicotine is a psychoactive chemical. Most RCTs attract participants by advertising the possibility of receiving free quitting products.[21] Plagued by an inability to blind experienced quitters as to their assignment,[22][23] some nicotine patch and gum studies acknowledge resorting to the use of active placebos delivering varying amounts of unbuffered nicotine.[24][25][26][27]

There are alternatives to randomized clinical trials that permit causal inferences, including randomized encouragement designs and observational studies employing matched sampling. [28]

Measuring expired carbon monoxide while ignoring nicotine/cotinine within body fluids, nicotine cessation was rarely assessed within smoking cessation RCTs. Instead, the accomplishment of quitters who succeeded in ending nicotine use was compared to quitters who continued non-indigenous chemical stimulation of their brain dopamine pathways for weeks or months via NRT, varenicline or bupropion.

I submit that a full and accurate real-world nicotine dependency recovery assessment has yet to occur. It cannot happen so long as nearly all quitting method surveys omit “cold turkey (abrupt nicotine cessation)” as a quitting option (see PATH & Toolkit survey questions) while conflating actual quitting methods with the planning, education, counseling, and support available to all methods, including cold turkey.

Nicotine Dependency Recovery

Ensuring that the nicotine-dependent patient is aware of their cessation starting point aids in establishing perspective about what needs to happen and the key to staying free. Nicotine dependency is real drug addiction in every sense, as permanent as alcoholism. There is no cure. Once free, the ex-user remains on lifetime probation.

PET scan research indicates that just 1-2 puffs from a cigarette cause 50% occupancy of nicotinic acetylcholine receptors (nAChRs) for 3.1 hours.[29] The high rate of return to regular smoking once a cigarette is tasted (88-95%) suggests that the distinction between an initial lapse (slip) and full relapse may be unnecessary.[30][31]

Despite peak nicotine withdrawal passing within 72 hours,[32] and the binding potential of nAChRs down-regulating to pre-dependency levels within 21 days,[33] urges and cravings associated with nicotine’s roughly 2-hour elimination half-life have deeply conditioned users to fear withdrawal, delay cessation, and make early withdrawal miserable.

Physicians, clinicians, and staff members are perfectly positioned to assist dependent patients in trading quitting for recovery, in helping them realize that feeling their healing is good, not bad. Imagine nicotine-dependent patients leaving the office excited about recovery, coming home, and their temporary journey of readjustment, instead of fearing, dreading, delaying, and fighting it.[34][35]

Key to abrupt cessation success is instilling in patients acceptance of the fact that, upon commencing recovery, while one puff would be too many and thousands not enough, it’s impossible to relapse so long as no nicotine enters their bloodstream.

References:

1. ↩ Rosen RL, Steinberg ML. Interest in quitting e-cigarettes among adults in the United States. Nicotine Tob Res. 2020 Apr 21;22(5):857-858. doi: 10.1093/ntr/ntz062. PMID: 31011747; PMCID: PMC7171275.

2. ↩ Huerne K, Eisenberg MJ. Vaping Cessation Interventions in Former Smokers: A Review. Can J Cardiol. 2023 Apr 27:S0828-282X(23)00368-9. doi: 10.1016/j.cjca.2023.04.020. Epub ahead of print. PMID: 37119945.

3. ↩ Webster’s New Collegiate Dictionary (1st ed). “cold turkey” 1973 G. & C. Merriam Co. (see https://whyquit.com/images/cold-turkey-defined-1973.jpg)

4. ↩ Tobacco Use and Dependence Guideline Panel. Treating Tobacco Use and Dependence: 2008 Update. Rockville (MD): US Department of Health and Human Services; 2008 May. Available from: https://www.ncbi.nlm.nih.gov/books/NBK63952/

5. ↩ Doran CM, Valenti L, Robinson M, Britt H, Mattick RP. Smoking status of Australian general practice patients and their attempts to quit. Addict Behav. 2006 May;31(5):758-66. doi: 10.1016/j.addbeh.2005.05.054. Epub 2005 Aug 31. PMID: 16137834.

6. ↩ Bassett JC, Matulewicz RS, Kwan L, McCarthy WJ, Gore JL, Saigal CS. Prevalence and Correlates of Successful Smoking Cessation in Bladder Cancer Survivors. Urology. 2021 Jul;153:236-243. doi: 10.1016/j.urology.2020.12.033. Epub 2021 Jan 13. PMID: 33450283.

7. ↩ Santi SA, Conlon MSC, Meigs ML, Davidson SM, Mispel-Beyer K, Saunders DP. Rates of Smoking Cessation at 6 and 12 Months after a Clinical Tobacco Smoking Cessation Intervention in Head and Neck Cancer Patients in Northern Ontario, Canada. Curr Oncol. 2022 Mar 2;29(3):1544-1558. doi: 10.3390/curroncol29030130. PMCID: PMC8947430.

8. ↩ Khariwala SS, Rubin N, Stepanov I, Nollen N, Ahluwalia JS, Nelson HH, Hatsukami DK. "Cold turkey" or pharmacotherapy: Examination of tobacco cessation methods tried among smokers prior to developing head and neck cancer. Head Neck. 2019 Jul;41(7):2332-2339. doi: 10.1002/hed.25708. Epub 2019 Feb 15. PMCID: PMC6579626.

9. ↩ Wang X, Lee NL, Burstyn I. Smokers' utilization of quitting methods and vaping during pregnancy: an empirical cluster analysis of 2016-2018 Pregnancy Risk Assessment Monitoring System (PRAMS) data in seven US states. BMC Pregnancy Childbirth. 2023 May 2;23(1):306. doi: 10.1186/s12884-023-05608-3. PM CID: PMC10152601.

10. ↩ Pierce JP, Cummins SE, White MM, Humphrey A, Messer K. Quitlines and nicotine replacement for smoking cessation: do we need to change policy? Annu Rev Public Health. 2012 Apr;33:341-56. doi: 10.1146/annurev-publhealth-031811-124624. Epub 2012 Jan 3. PMID: 22224888.

11. ↩ Leas EC, Pierce JP, Benmarhnia T, White MM, Noble ML, Trinidad DR, Strong DR. Effectiveness of Pharmaceutical Smoking Cessation Aids in a Nationally Representative Cohort of American Smokers. J Natl Cancer Inst. 2018 Jun 1;110(6):581-587. doi: 10.1093/jnci/djx240. PMCID: PMC6005055.

12. ↩ Fekom M, Aarbaoui TE, Guignard R, Andler R, Quatremère G, Ducarroz S, Nguyen-Thanh V, Melchior M. Use of tobacco cessation aids and likelihood of smoking cessation: A French population-based study. Prev Med Rep. 2022 Nov 12;30:102044. doi: 10.1016/j.pmedr.2022.102044. PMCID: PMC9747661.

13. ↩ Jackson SE, Kock L, Kotz D, Brown J. Real-world effectiveness of smoking cessation aids: A population survey in England with 12-month follow-up, 2015-2020. Addict Behav. 2022 Dec;135:107442. doi: 10.1016/j.addbeh.2022.107442. Epub 2022 Jul 25. PMCID: PMC9587352.

14. ↩ Pierce JP, Benmarhnia T, Chen R, White M, Abrams DB, Ambrose BK, et al. Role of e-cigarettes and pharmacotherapy during attempts to quit cigarette smoking: The PATH Study 2013-16. PLoS One. 2020 Sep 2;15(9):e0237938. doi: 10.1371/journal.pone.0237938. PMCID: PMC7467279.

15. ↩ Jackson SE, Kotz D, West R, Brown J. Moderators of real-world effectiveness of smoking cessation aids: a population study. Addiction. 2019 Sep;114(9):1627-1638. doi: 10.1111/add.14656. Epub 2019 Jul 6. PMCID: PMC6684357.

16. ↩ Kotz D, Brown J, West R. Prospective cohort study of the effectiveness of smoking cessation treatments used in the "real world". Mayo Clin Proc. 2014 Oct;89(10):1360-7. doi: 10.1016/j.mayocp.2014.07.004. PMCID: PMC4194355.

17. ↩ Pierce JP, Gilpin EA. Impact of over-the-counter sales on effectiveness of pharmaceutical aids for smoking cessation. JAMA. 2002 Sep 11;288(10):1260-4. doi: 10.1001/jama.288.10.1260. PMID: 12215133.

18. ↩ Ferguson SG, Shiffman S, Gitchell JG, Sembower MA, West R. Unplanned quit attempts--results from a U.S. sample of smokers and ex-smokers. Nicotine Tob Res. 2009 Jul;11(7):827-32. doi: 10.1093/ntr/ntp072. Epub 2009 Jun 9. PMID: 19509277.

19. ↩ West R, Sohal T. "Catastrophic" pathways to smoking cessation: findings from national survey. BMJ. 2006 Feb 25;332(7539):458-60. doi: 10.1136/bmj.38723.573866.AE. Epub 2006 Jan 27. PMCID: PMC1382540.

20. ↩ Aubin HJ, Bobak A, Britton JR, Oncken C, Billing CB Jr, Gong J, et al. Varenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open-label trial. Thorax. 2008 Aug;63(8):717-24. doi: 10.1136/thx.2007.090647. Epub 2008 Feb 8. PMCID: PMC2569194.

21. ↩ USDHHS, Join a research study. https://smokefree.gov/tools-tips/get-extra-help/join-a-research-study Accessed May 14, 2023.

22. ↩ Mooney M, White T, Hatsukami D. The blind spot in the nicotine replacement therapy literature: assessment of the double-blind in clinical trials. Addict Behav. 2004 Jun;29(4):673-84. doi: 10.1016/j.addbeh.2004.02.010. PMID: 15135549.

23. ↩ Polito JR. Smoking cessation trials. CMAJ. 2008 Nov 4;179(10):1037-8; author reply 138. doi: 10.1503/cmaj.1080096. PMCID: PMC2572671.

24. ↩ Campbell IA, Prescott RJ, Tjeder-Burton SM. Transdermal nicotine plus support in patients attending hospital with smoking-related diseases: a placebo-controlled study. Respir Med. 1996 Jan;90(1):47-51. doi: 10.1016/s0954-6111(96)90244-9. PMID: 8857326.

25. ↩ Sønderskov J, Olsen J, Sabroe S, Meillier L, Overvad K. Nicotine patches in smoking cessation: a randomized trial among over-the-counter customers in Denmark. Am J Epidemiol. 1997 Feb 15;145(4):309-18. doi: 10.1093/oxfordjournals.aje.a009107. PMID: 9054234.

26. ↩ Ahluwalia JS, Richter K, Mayo MS, Ahluwalia HK, Choi WS, Schmelzle KH, Resnicow K. African American smokers interested and eligible for a smoking cessation clinical trial: predictors of not returning for randomization. Ann Epidemiol. 2002 Apr;12(3):206-12. doi: 10.1016/s1047-2797(01)00305-2. PMID: 11897179.

27. ↩ Jarvis MJ, Raw M, Russell MA, Feyerabend C. Randomised controlled trial of nicotine chewing-gum. Br Med J (Clin Res Ed). 1982 Aug 21;285(6341):537-40. doi: 10.1136/bmj.285.6341.537. PMID: 6809161; PMCID: PMC1499070.

28. ↩ West SG, Duan N, Pequegnat W, Gaist P, Des Jarlais DC, Holtgrave D, et al. Alternatives to the randomized controlled trial. Am J Public Health. 2008 Aug;98(8):1359-66. doi: 10.2105/AJPH.2007.124446. Epub 2008 Jun 12. PMCID: PMC2446460.

29. ↩ Brody AL, Mandelkern MA, London ED, Olmstead RE, Farahi J, Scheibal D, et al. Cigarette smoking saturates brain alpha 4 beta 2 nicotinic acetylcholine receptors. Arch Gen Psychiatry. 2006 Aug;63(8):907-15. doi: 10.1001/archpsyc.63.8.907. PMCID: PMC2773659.

30. ↩ Brandon TH, Tiffany ST, Obremski KM, Baker TB. Postcessation cigarette use: the process of relapse. Addict Behav. 1990;15(2):105-14. doi: 10.1016/0306-4603(90)90013-n. PMID: 2343783.

31. ↩ Garvey AJ, Bliss RE, Hitchcock JL, Heinold JW, Rosner B. Predictors of smoking relapse among self-quitters: a report from the Normative Aging Study. Addict Behav. 1992;17(4):367-77. doi: 10.1016/0306-4603(92)90042-t. Erratum in: Addict Behav 1992 Sep-Oct;17(5):513. PMID: 1502970.

32. ↩ McLaughlin I, Dani JA, De Biasi M. Nicotine withdrawal. Curr Top Behav Neurosci. 2015;24:99-123. doi: 10.1007/978-3-319-13482-6_4. PMCID: PMC4542051.

33. ↩ Mamede M, Ishizu K, Ueda M, Mukai T, Iida Y, Kawashima H, et al. Temporal change in human nicotinic acetylcholine receptor after smoking cessation: 5IA SPECT study. J Nucl Med. 2007 Nov;48(11):1829-35. doi: 10.2967/jnumed.107.043471. Epub 2007 Oct 17. PMID: 17942810.

34. ↩ Polito JR, 100 reasons to get excited about quitting smoking. https://whyquit.com/pr/012717.html Accessed 05/14/23

35. ↩ Polito, JR, 115 reasons to stop vaping. https://whyquit.com/pr/032023-reasons-to-stop-vaping.html Accessed 05/14/23

---

John R. Polito received his JD from the University of South Carolina School of Law in 1985, where he graduated Wig & Robe. He is a former 3-pack-a-day thirty-year smoker and the 1999 founder of WhyQuit. A nicotine cessation educator since 2000, John mentored under Joel Spitzer for two decades, presenting more than 100 live nicotine dependency recovery programs modeled after Joel's programs. He is the author of "Freedom from Nicotine - The Journey Home," "Smart Turkey," 6 peer-reviewed journal articles, and founder and director of Turkeyville, a 15,000-member Facebook support group exclusively for cold turkey quitters. Email: johnpolito54@gmail.com

---

---